Monday, February 27, 2017

Why do so many Indian gynecologists believe that all infertile women have TB ?

I recently attended an IVF conference in Delhi, and came away with the impression that a lot of IVF doctors there seem to feel that every Indian patient who's infertile has tuberculosis. They feel that it's a ubiquitous disease, and that the only reason we don't diagnose it for everyone is because we don't look for it hard enough.

Their " impression" is based on their personal experience with their own patients, and they don't care what the foreign medical literature shows. After all , TB is extremely common in India, and very rare elsewhere, so why would foreigners know anything about genital TB? This means that Indian doctors are the experts on this disease, so they can get away with any claim they choose to make. They see TB everywhere and anywhere, and I don't think any of their patients has not been subjected to anti-TB treatment.

They seem to be desperate to find TB in all their patients - and this sometimes seems to become an obsession with some of them. They will run an entire battery of tests in order to make this diagnosis, to prove that their "clinical impression" is correct.

Yes, there are patients in India who are infertile because of genital TB, but TB is becoming uncommon in India. Ironically, the problem is not the TB anymore - it's the misdiagnosis and overdiagnosis by poorly informed IVF doctors which causes infertile women much more harm !

There are standard established methods for making the diagnosis of TB, but when these doctors run a single test and get a negative result, they do another one. If that's still negative, they do a third; and if that's negative as well, they do a fourth, until they finally get one test result which is finally abnormal. They then triumphantly point to that result and tell the patient, "See, we found the TB , and now we need to start your treatment." In some cases, even if all the results are normal, they will still start the treatment "empirically" based on their clinical judgment and experience !

It's only when they finally " treat " these patients with antiTB drugs are they satisfied, because they refuse to believe that infertile patients could not have TB. It's hard for me to understand why they have this single-minded obsession with unearthing TB ! Here's a typical example. They start by doing an endometrial biopsy, and sending it for culture, which is the gold standard for making the diagnosis. If this is negative, they say - Yes, we all know that there are lots of false negative, so let's do more advanced tests, because it's not very sensitive, and can miss the diagnosis.

They then send it for PCR testing , which is a grossly unreliable test, because the slides are often contaminated with environmental mycobacteria, and the PCT tests cannot differentiate between the bacilli which cause genital tuberculosis , and the environmental bacilli , which are ubiquitous. If that also comes negative, they do another fancy test called gamma interferon; or a blood test called TB gold; or a Mantoux test. If all these are negative, they resort to doing a PAMP test ( a esoteric, expensive and exotic test, which is available in only one clinic in the entire world - which should tell you all you need to know about its reliability !)

Many doctors don't even bother to do the tests in this organised sequence. They just send the endometrial tissue sample for all the tests at one time during the routine workup, using the crude principle of brute force ! Now, if out of these 10 tests, nine are negative, and one is positive, they'll point out to that abnormal result triumphantly and say, "See, we finally found that elusive tubercle bacillus, which was lurking in your body. Everyone else missed it, but now that we have identified it, we need to treat you, so you can finally get pregnant."

What I can't understand is out of 10 tests , if nine are negative, doesn't that mean that the patient doesn't have that disease? However, they are in no mood to apply common sense. They will not rest until they get a positive result, and they won't let their poor patients rest either !

This overtesting and overtreatment causes a lot of harm. Needless to say, it doesn't improve their fertility, because they never had TB in the first place. Yes, some patients will get pregnant after taking the TB medications, but they would most likely have got pregnant even if they hadn't taken them ! What's worse is that these drugs can damage the liver, and kidneys, because they are toxic and need to be taken for many months. Also, because patients waste valuable time taking these anti- TB drugs, they end up reducing their chances of getting pregnant.

The problem is that once the doctor's mind has been made up, he is wedded to his beliefs. He refuses to believe any evidence which could challenge his ideas. The problem becomes worse as they get older, because their attitudes harden along with their arteries as they age. They are very selective about what they are willing to listen to, and if anyone disagrees with they, they will disregard their opinion as being rubbish. After all, aren't they the world authority on this topic ? How dare anyone challenge them? Any paper which dares to differ is a load of rubbish - either because the doctor who published it didn't know what he was doing; or because the tests they used weren't sophisticated enough.

This is the reason they do all their tests only in one single laboratory, because ( according to them) no other laboratory is equipped to provide the accuracy and precision which they require ! This makes absolutely no sense to me. It's all eminence-based medicine, based on an individual doctor's opinion.

As they grow older, they acquire positions of power. The become the opinion leaders in the community, and lots of other doctors blindly follow whatever they say, simply because they don't know any better. This is how these flawed beliefs have come to dominate the worldview of IVF specialists today .

What I find especially fascinating is that no respected TB specialist agrees with the results of their tests - and yet they merrily continue "treating" lots of hapless women with antiTB drugs !
If this problem was restricted to only a few IVF clinics, it wouldn't be so bad. However, because these doctors are leading professors who give talks at medical conferences, many practising gynecologists get brainwashed into believing them. Sadly, most doctors are not taught how to think critically. They are intellectually lazy, and happy to believe what the experts say. When a message is mindlessly repeated many times, it starts becoming perceived as gospel truth, even though it is false. This is why we are now seeing an epidemic of overdiagnosis and overtreatment of genital TB .

My fear is that this will have a long-term public health impact, because the indiscriminate use of antiTB medicines will lead to the emergence of MDR - multi-drug resistant TB. I do hope the public health department starts insisting that all patients who are put on anti-TB medicines because they have been diagnosed as having genital TB are reported to the government, so we can curb this menace before it gets out of hand.

Has your doctor told you that you have TB ? Need help in getting pregnant ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you !

3 comments:

Hi DoctorMy doctor had mentioned that she might do TB PCR test if my current cycle failed.

I have a 6 year old daughter I conceived naturally and delivered in 2010. then in 2015 I had conceived through a clomid cycle and it was a miscarriage. Since then I am unable to conceive. I had few cycles of clomid then I left all that and again tried naturally with acupuncture but no luck. My doctor gave me Tamoxifen in my last cycle and did an IUI. She was hopeful I would conceive. But I didn't. So she told me to just rule out she wants to do this test as its common in India.

this month she told just relax and based on the result we will decide next course of action.

I am 36 years old. I am mentally tired now. I don't know which doctor is correct and what treatment is right. I have already changed 3 doctors. All my test are normal, My AMH FSh thyroid HSG SA everything looks ok. only the prolactin was on the higher side it was something 35.

Please suggest if I am on the right track.She plans to start FSH injections for one cycle if all seems fine.

Just wantd to add that she took the endometrium sample and has sent for test. reading all your articles I am kind of confused that is the right thing I am doing. I hope you will thro some light on this and guide me on this.

These TB PCR tests are very unreliable ! You can read more about this at http://blog.drmalpani.com/2015/03/laboratory-tb-versus-genital-tb.htmlPlease do NOT waste your time and money or risk your health with the toxic antiTB drugs

I agree that IVF (www.drmalpani.com/our-services/ivf) would be your best treatment optionas it would maximise your chances of conceiving quickly.

Time is now at a premium for you - please don't waste it ! You should never have any regrets that you left any stone unturned and didn't give yourself the best shot at fertility treatment.